Saturday, July 23, 2016

The Burnout Disease

I got an ominous e-mail from the Psychiatric Times yesterday.  The title was "Before it's too late".  It reminded me that at some point the professional trades are just like everybody else - desperately vying for attention through provocative headlines.  The irony is that that there are numerous areas in medicine and psychiatry that could be labeled in this manner but are routinely ignored.  I recently point out that detoxification services and the shortage of psychiatrists have been ignored for 30 years.   It may be accurate to say there was a lot of lip service paid to the psychiatrist shortage with no real action.  At any rate I decided to click on the provocative e-mail to see what the new risk was and was taken to a set of 6 slides on burnout or more accurately "6 Strategies To Prevent Physician Burnout." by Eva Szigethy, MD, PhD.

The presentation begins with a definition of burnout as chronic exhaustion and decreased interest in work.   Three stages were defined with more mild and transient symptoms in Stage 1 progressing to Stage 3 with chronic symptoms that progress to psychiatric and physical disorders.  That basic definition contains a lot of information and assumptions.  The basic assumption is that a person must be interested in work.  I have certainly encountered people who were interested in work, but they are generally few and far between.  If I had to globally characterize them, they tend to be people who bring a lot of creativity and skill to a particular job and for various reasons they are allowed to use that creativity and skill in an optimal way.  I don't think that those characteristics map onto any particular degree or occupation.  I think it is probably the driving force behind why people want to work for themselves or establish their own businesses.  There is no better way to maintain a high level of interest in work than to be working for yourself.   The introduction of any management hierarchy is a potential threat to interest in work.

There are also a large number of jobs (if not most jobs) where people work very hard and are not rewarded.  Oren Nimni wrote an interesting article about this in Current Affairs while commenting on the recent plagiarism concern about a political speech.  He points out that the American economy is fundamentally skewed and unfair and political speeches about values, hard work and achievement based on merit do not necessarily apply.  He is blunt about telling people that hard work will necessarily get them somewhere is a cruel lie (par 10).  Many of the jobs he is referring to here are physically exhausting and as a physician, I can say with certainty have a high probability of injury and disability.  It is difficult if not impossible to work at many of these jobs until you are old enough to retire.  The path I observe is that when you are too disabled to do one of these jobs, you move onto to a more sedentary and even lower paying job.  This may be an entire group of workers for whom the idea of burnout is a luxury.  Every day is exhausting whether you have physically adapted to the circumstances of the job or not.  When I think about these definitions of burnout, they necessarily don't apply to a lot of occupations.

The Psychiatric Times slides go on to identify the early markers in the burnout process and what can be done to prevent them.  They start out with an assessment of the weekly schedule and eliminating nonessential tasks.  There is the implicit assumption that the potential burnout casualty is in control of the schedule.  I can say with certainty that every person who I have ever seen who was anxious or depressed as a direct result of their work environment - this is never true.  In fact, the people in control of the schedules tend to be some of the most unpleasant people.  They work from a general concept that work is standardized, everyone needs to do it the same way, and if workers don't like it - they can always find another job.  Those work environments are partitioned into highly reimbursed professionals who have to tolerate out of control managers and non-professionals who have to put up with similar management.  The professionals may have slightly more leverage in the workplace.   In the case of physicians, they used to have leverage because of legal requirements in many healthcare settings.  Managers have found their way around these requirements and in practically all organizations there is a chain of command that involves physicians being ordered around by nonphysicians with no medical expertise.  What constitutes management expertise is anybody's guess.

The suggested strategy to assess various professional goals and the impact of the work on the physician is the next step.  In an ideal world there would be some freedom to move laterally within organizations or between roles.  In the regimented world of physician employees and managed care organizations it is next to impossible.  One of the biggest burnout factors for physicians is the measurement of so-called productivity.  Productivity expectations in most organizations are a setup for overwork and overinvolvement in the most mindless aspects of medical practice - billing and coding and the electronic health record (EHR).   There is no room for breaks, sleep, or intellectually stimulating activity.  The entire process is driven by management and the final product (in spite of all the hype) is an inferior one.  I have written on several occasions about how the most elaborate and expensive EHR - costing millions per year in licensing fees cannot seem to produce a coherent report that I could print from a hundred dollar software package in the 1990s.  And that doesn't take into account that every physician in America is now a scribe in this process - producing terabytes per day of useless data - used only for billing and coding purposes.

The human factor in burnout especially for physicians is always a huge question mark.   Who can you turn to?  One of the colleagues in your system who in all probability is as burned out as you?  A colleague outside of your system who has successfully evaded corporate medicine and is quite happy to advise you on how to do the same?  Most physicians in this situation feel trapped either way.  Many have been able to escape medicine completely, either working for less or in medical industries.  In advising colleagues over the years, jobs within the industry are far more difficult to get - almost impossible if you are middle aged and have been focused on nothing but productivity for decades.  Often the best outcome is to settle for less and retire, especially if there are signs that mental and physical health are being affected.  Under duress many physicians add to the problem.  They get involved in management specifically utilization review or similar rationing jobs for managed care companies.  I have also encountered physicians who view themselves as being disruptive and who tell me that I need to learn how to "play in the sandbox" with the other health care managers.  They teach physicians management as though anything but managed care rationing strategies are likely to apply.  That may be a temporary solution for that particular individual.  At a personal level, I would not be able to suspend my knowledge of medicine and psychiatry to make arbitrary cash decisions for my employer.  But clearly that is just me.  Plenty of physicians have gone that route.

The final consideration of vacations is also not a good solution.  Although it has not been studied, I can predict that any physician with a serious burnout problem will feel almost as bad on the first day back from vacation as the day they left.  By day 2 they certainly will feel as bad.  Many work environments for physicians these days are hostile territory.  The goal is really to get in and get out with as minimal damage as possible.  Many will leave as early as they can and if they have remote EHR access - work from home into the night.  I have called primary care clinics at  7PM and talked to a physician amid a flurry of typing sounds and mouse clicks from their colleagues in the background.  There is no way that you can walk into that environment and not feel burned out.

My conclusion about burnout is basically unchanged from an earlier post.  If the Psychiatric Times, had invited me to made a slide set (that won't happen anytime soon) - it would have been just one slide:


George Dawson, MD, DFAPA


1:  Eva Szigethy.  6 Strategies to Prevent Physician Burnout.  Psychiatric Times.  July 22, 2016.

2:  Oren Nimni.  Melania's plagiarism actually just shows how vapid political speeches are.  Current Affairs.  July 19, 2016.

3:  My previous posts on Burnout.



  1. I politely pointed out on the comments that most of those strategies would also work for POWs or chattel workers but that doesn't address the real issue. In other words, this kind of thinking deflects blame. Psychiatric Times editors, being the sensitive souls that they are, elected to scrub my disruptive post.

    1. Well thanks for posting it here.

      It takes a surprisingly long time for physicians to realize that they initially sold the farm and then had it forcibly taken away. Hopefully blaming themselves for burnout while they are being worked to death by a coalition of mindless bureaucrats and financial opportunists will be the last vestige of self flagellation.

      But there is that problem that the current generations have been so thoroughly indoctrinated into the "productivity, evidence-based, collaborative care, cost effectiveness" pseudo intellectual doublespeak - to the point where nothing outside of that has meaning any more.

      Nobody knows where to go in the hospital anymore without a morning huddle around a representative of the administration.

      Did Orwell have a term for burnout?

  2. I view moral masochism as a form of fetish and very hard to correct. The image in my mind is the albino self-flagellating monk from Da Vinci code. Some doctors see it as a calling like the priesthood. The problem with that is that there is a brain drain in the priesthood since smart people who want to have kids go somewhere else. Melissa Mayer, a failure as Yahoo CEO, but safely riding gilded parachute, doesn't regret not going to medical school.

  3. By the way, Psychiatric Tiimes is at again with more trivializing administrative blame pieces on burnout. Hope you don't mind that I linked to this article and one of Dr. Wible's (who I mostly but do not wholly agree with). Naturally their reaction was that this was "inflammatory".